Provider Demographics
NPI:1982061750
Name:LT PROACTIVE CARE CLINIC NEVADA - FARBAKHSH PLLC
Entity Type:Organization
Organization Name:LT PROACTIVE CARE CLINIC NEVADA - FARBAKHSH PLLC
Other - Org Name:LT PROACTIVE CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMBIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:FARBAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-554-5257
Mailing Address - Street 1:2901 CORPORATE PL
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4560
Mailing Address - Country:US
Mailing Address - Phone:612-554-5257
Mailing Address - Fax:
Practice Address - Street 1:121 CARNEGIE ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7118
Practice Address - Country:US
Practice Address - Phone:702-802-7357
Practice Address - Fax:702-802-7356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty